Stroke- Suspected (Outside of hospital)

1 Information resources for patients and carers

• 'Diet and Hypertension'(PDF) from British Dietetic Association

• 'Stroke' (PDF) from Brain & Spine Foundation at

• 'Stroke' (URL) from Datapharm at

• 'Stroke' (URL) from Patient UK at

• 'Stroke and high blood pressure' (URL) from Blood Pressure Association at

• Sue Ryder Care at

• The Carers Resource at

• The Disabled Living Foundation at

• The Stroke Association at

• 'Understanding NICE guidance: Early assessment and treatment of people who have had a stroke or transient ischaemic attack (TIA)' (PDF) from National Institute for Health and Clinical Excellence

Information for carers and people with disabilities is available at:

• 'Caring for someone' (URL) from Directgov at http://www.direct.gov.uk

• 'Disabled people' (URL) from Directgov at http://www.direct.gov.uk

Explanations of clinical laboratory tests used in diagnosis and treatment are available at ‘Understanding Your Tests’ (URL) from Lab Tests Online-UK at

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2Stroke - clinical presentation

Symptoms and signs of stroke develop rapidly, are usually focal (although they can be global), and include:

  • numbness
  • weakness or paralysis:
  • may be confined to face, arm or leg only
  • problems with speech and comprehension
  • slurred speech
  • visual disturbances (characteristically a sudden visual loss in one half of the visual field, or visual loss in one quarter of the visual field, or visual loss in one eye)
  • disorder of perception
  • disorder of balance
  • coordination disorder
  • decreased consciousness or coma
  • confusion
  • acute problems with swallowing
  • acute headache with or without nausea or vomiting

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3 Exclude hypoglycaemia

Hypoglycaemia is:

  • a stroke mimic
  • defined as a blood glucose of less than 4mmol/L

Exclude hypoglycaemia:

  • as the cause of symptoms in patients with sudden onset of neurological symptoms
  • suspect hypoglycaemia in people who abuse alcohol or who are being treated for diabetes mellitus (DM; with drugs other than metformin):
  • hypoglycaemic symptoms can occur at a higher blood glucose levels in those with diabetes

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4 Perform face, arm, speech test (FAST)

Use face, arm, speech test (FAST) to screen for diagnosis of stroke:

  • new onset facial weakness:
  • ask the patient to smile or show their teeth
  • the FAST test is positive if there is new facial asymmetry, e.g. the mouth or eye droops
  • new onset arm weakness:
  • raise the patient's arms to 90° if they are sitting or 45° if they are lying
  • ask the patient to maintain the position when you let go
  • the FAST test is positive if, when you let go, one arm falls or drifts down
  • speech problems:
  • assess patient's speech and determine whether it is slurred or the person has difficulty finding the name for commonplace objects, e.g. cup, table, chair, keys, pen
  • if they have difficulty seeing, place the objects in their hands
  • if they have a companion, check whether this is a new problem
  • the FAST test is positive if there is a new unexplained speech problem

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5 FAST test positive – perform ROSIER- immediate referral (call 999)

Make a working diagnosis of stroke if the face, arm, speech test (FAST) is positive, i.e. failed:

  • Undertake a Recognition of Stroke in ER (A&E) ROSIER Score
  • call 999
  • immediate assessment using a standardised tool and then transfer by ambulance is routinely indicated for people with new or developing stroke-like symptoms
  • as the patient might be eligible for thrombolytic treatment, ensure that ambulance control understands the urgency of the situation and that the person needs to be taken immediately to the nearest hospital with facilities for stroke thrombolysis
  • patients presenting directly to A&E should be assessed using the ROSIER scale
  • patients with suspected stroke should be immediately transferred to a hospital providing hyperacute services 24 hours a day- this includes:
  • a stroke triage system
  • expert clinical assessment
  • rapid imaging
  • the ability to deliver intravenous (IV) thrombolysis
  • patients should receive an early multidisciplinary assessment, including swallow screening, and have prompt access to a high quality stroke unit
  • thrombolysis should only be provided when all the other components of acute stroke care are of high quality
  • emergency medical services should be redesigned to facilitate rapid access to specialist stroke services
  • minor stroke presenting after 4.5 hours should be managed in the same way as transient ischaemic attacks (TIAs):
  • thrombolysis up to 3 hours is currently licensed but expert opinion suggests there is further limited benefit if thrombolysis is given within 3 and 4.5 hours of onset of stroke
  • a small number of people have severe co-morbidity and might not benefit from admission:
  • discuss with the patients and their family/carer
  • clearly document reasons if the decision is made not to admit
  • some patients who become asymptomatic may be considered for urgent outpatient investigation and treatment (seek the advice of the stroke team)

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6 FAST test negative - history and examination

Assess history:

  • weakness or numbness of the face, arm, or leg (especially if only on one side of the body)
  • problems with speech and comprehension
  • problems with swallowing
  • problems with walking, balance, or coordination
  • loss of vision
  • confusion
  • headache with or without nausea or vomiting
  • decreased conscious state or coma

Perform a full neurological examination, especially:

  • examination of power
  • examination of speech and comprehension
  • examination of visual fields
  • examination of cranial nerves
  • coordination
  • examination of sensation

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8History suggestive of transient ischaemic attack (TIA) or minor stroke?

Any patient who presents with a history of transient neurological symptoms suggestive of a cerebrovascular event should be considered to have had a transient ischaemic attack (TIA) - if the symptoms persist the diagnosis of stroke should be suspected.

Diagnose TIA if the person has had transient (lasting less than 24 hours) neurological symptoms that suggest a focalcerebrovascular event, and are otherwise unexplained:

  • most second strokes occur within 24 hours of initial ischaemic event
  • common causes of early recurrent event are carotid stenosis or atrial fibrillation (AF)

Some patients who are asymptomatic when seen may be considered for urgent outpatient investigation and treatment (seek theadvice of the stroke team).

Perform ABCD2 score:

  • ABCD2 is calculated based on:
  • A- age over 60 years (1 point)
  • B- blood pressure (BP) at presentation - BP equal to or above 140/90mmHg or a history of hypertension (1 point)
  • C- clinical features - unilateral weakness (2 points) or problems with speech (1 point)
  • D- duration of symptoms lasting longer than 10 minutes - symptoms lasting over 1 hour (2 points), and symptoms lasting10-59 minutes (1 point)
  • D - presence of diabetes mellitus (DM; 1 point)

The total scores range from 0 (low risk) to 7 (high risk) - if the score is 4 or more then there is a high risk of an early recurrent ischaemic event.

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10 No - consider differential diagnoses and manage accordingly

Differential diagnoses include:

  • subdural haematoma
  • cerebral vein thrombosis
  • intracranial mass, e.g. tumour
  • metabolic disorders, e.g. hypoglycaemia
  • seizures
  • encephalitis
  • global ischaemia
  • labyrinthine disorders
  • temporal arteritis
  • migraine
  • psychological disorders, e.g. anxiety or panic disorder
  • multiple sclerosis (MS)
  • disorders of the peripheral nerves
  • transient global amnesia
  • trauma

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References

Approval Date: June 2011Page 1 of 5

Review Date: June 2013